Rob A. C. Bilo

Birth-related mid-posterior rib fractures in neonates: a report of three cases (and a possible fourth case) and a review of the literature

BackgroundPosterior rib fractures in young children have a high positive predictive value for non-accidental injury (NAI). Combined data of five studies on birth trauma (115,756 live births) showed no cases of rib fractures resulting from birth trauma. There have, however, been sporadic cases reported in the literature.ObjectiveWe present three neonates with both posterior rib fractures and ipsilateral clavicular fractures resulting from birth trauma. A review of the literature is also presented. The common denominator and a possible mechanical aetiology are discussed.Materials and methodsIn total, 13 cases of definitive birth-related posterior rib fractures were identified.ResultsNearly all (9/10) posterior rib fractures were (as far as reported in the original publications) in the midline. In 12 of the 13 children, birth weight was high and in 7 children birth was complicated by shoulder dystocia. An interesting finding was that in cases where a clavicular fracture was present, this was on the ipsilateral side.ConclusionRadiologists, when presented with a neonate with posterior rib fractures, should be aware of this rare differential diagnosis.

Subdural hematomas: glutaric aciduria type 1 or abusive head trauma? A systematic review

PurposeGlutaric aciduria type 1 (GA1) is a rare metabolic disorder of glutaryl-CoA-dehydrogenase enzyme deficiency. Children with GA1 are reported to be predisposed to subdural hematoma (SDH) development due to stretching of cortical veins secondary to cerebral atrophy and expansion of CSF spaces. Therefore, GA1 testing is part of the routine work-up in abusive head trauma (AHT). This systematic review addresses the coexistence of GA1 and SDH and the validity of GA1 in the differential diagnosis of AHT.MethodsA systematic literature review, with language restriction, of papers published before 1 Jan 2015, was performed using Pubmed, PsychINFO, and Embase. Inclusion criteria were reported SDHs, hygromas or effusions in GA1 patients up to 18xa0years of age. Of 1599 publications, 20 publications were included for analysis.ResultsIn total 20 cases, 14 boys and 6 girls, were included. In eight cases (40xa0%) a child abuse work-up was performed, which was negative in all cases. Clinical history revealed the presence of trauma in eight cases (40xa0%). In only one case neuroradiology revealed no abnormalities related to GA1 according to the authors, although on evaluation we could not exclude AHT.ConclusionFrom this systematic review we conclude that SDHs in 19/20 children with GA1 are accompanied by other brain abnormalities specific for GA1. One case with doubtful circumstances was the exception to this rule.

General Aspects of Fractures in Child Abuse

The incidence and prevalence of child abuse is unknown. The reason for this is that in nearly every study to establish the incidence and prevalence, researchers use their own definition. Sometimes this is a ‘broad definition,’ such as that of the World Health Organisation (WHO): ‘Child abuse, sometimes referred to as child abuse and neglect, includes all forms of physical and emotional ill-treatment, sexual abuse, neglect, and exploitation that results in actual or potential harm to the child’s health, development or dignity. Within this broad definition, five subtypes can be distinguished - physical abuse; sexual abuse; neglect and negligent treatment; emotional abuse; and exploitation’ [1]. In other cases a much narrower definition is used by preference. This makes it impossible or nearly impossible to compare the research results for incidence and prevalence. In his report on the occasion of the violent death of Victoria Climbie on 25 February 2000, Lord Laming writes on the incidence and prevalence of child abuse: ‘I have no difficulty in accepting the proposition that this problem (deliberate harm to children) is greater than that of what are generally recognized as common health problems in children, such as diabetes or asthma’ [2].

Normal Variants, Congenital and Acquired Disorders

Although in the differential diagnosis of fractures sustained in childhood one should be particularly aware of accidental trauma, it was found that congenital and acquired defects regularly give rise to suspicions of child abuse (see Table 7.1). Based on a combination of patient history, laboratory tests and radiological examination, it is usually possible to reach the correct diagnosis. In this chapter we discuss the most important disorders of which the radiological images could fit the criteria for child abuse.

Evidence-Based Imaging in Non-CNS Nonaccidental Injury

■ Child abuse is a serious health problem with severe long-term consequences and high societal costs (strong evidence).

Clavicles, Scapulas, Sternum, Vertebrae and Pelvis

The clavicle is situated at the front-/upper side of the ribcage, between the shoulder girdle and the sternum. For the greater part its course is clearly visible, just underneath the skin, and easily palpable along its full length. Fractures of the clavicle are amongst the most frequently found fractures, in children as well as in adults. In children it may well be the most prevalent fracture [1].

Radiology in Suspected Child Abuse

Even before Kempe published his now classic article on ‘the battered child syndrome’ in 1962 [1], radiologists drew attention to fractures that could really only be explained by the impact of external mechanical force. In 1946, Caffey was the first to describe the relation between the presence of multiple fractures of the long bones and subdural haematomas in six children in whom no previous trauma was known [2]. He thought it remarkable that in a number of children no new anomalies were found while hospitalised; however, some children showed new manifestations as soon as they returned home. Based on the fact that in children subdural haematomas are usually of traumatic origin, he suspected that this combination had a traumatic origin. In 1953, Silberman established that the combination of injuries as described by Caffey had to have a traumatic background [3]. In 1955, Woolley was the first to conclude that the found anomalies were the result of ‘intentionally’ inflicted physical injuries [4]. In 1957, 11 years after his original publication, Caffey concluded that abuse by either one or both parent(s) could be a possible explanation for this combination of injuries [5].